ENT Flashcards
1
Q
If you see speech delay in an infant or toddler, what should you suspect?
A
Hearing loss
2
Q
What are some clues to hearing loss in older children?
A
- Ignoring commands
2. Increased volume of TV or music
3
Q
What are the 2 types of hearing loss?
A
- Conductive
2. Sensorineural
4
Q
What occurs when sound fails to progress to the cochlea?
A
Conductive hearing loss
5
Q
Where can obstruction occur in conductive hearing loss?
A
Anywhere from external canal to ossicles
6
Q
What is the most common cause of conductive hearing loss?
A
Effusion (usually due to OM)
Effusion is present in the absence of inflammation
7
Q
Which type of hearing loss is often correctable with surgery or hearing devices?
A
Conductive
*Sensorineural are less-often correctable
8
Q
What is needed to facilitate language development in children with all forms of hearing loss?
A
EI
9
Q
What syndromes is hearing loss associated with?
A
- CHARGE
2. Syndromes involving cleft lip and palate
10
Q
If you have a patients with an external or middle ear malformation, what else should you consider?
A
Craniofacial, renal, or inner ear malformations
11
Q
What causes the most severe degree of conductive hearing loss?
A
Small, malformed ears (microtia or aural atresia)
12
Q
What can large perforations from trauma result in?
A
Significant conductive hearing loss
13
Q
What is post-taumatic conductive hearing loss usually associated with (besides perforation)?
A
Disruption of ossicles themselves
14
Q
What is tympanosclerosis?
A
Scarring on TM (usually after recurrent OM)… results in minimal conductive hearing loss
15
Q
What is the most common cause of conductive hearing loss?
A
OM with effusion
16
Q
What is the result of keratinization of the epithelial cells in the middle ear?
A
Cholesteatoma
17
Q
9 year old body, purulent discharge from right ear over several months despite several courses of antibiotics. On PE there is retraction of TM and sqamous debris. What next?
A
Refer to ENT… this is a cholesteatoma
18
Q
How are cholesteatomas managed?
A
Surgical removal- Technically benign, but they expand and destroy bone
19
Q
Late recognition of what ear findings is a major cause of permanent hearing loss?
A
Cholesteatome
20
Q
Foul smeeling discharge despite treatment of a perforated TM is a clue to what?
A
Cholesteatoma
21
Q
What causes sensorineural hearing loss?
A
Malfunction of cochlea and/or auditor nerve
22
Q
What are 4 general causes of sensorineural hearing loss?
A
- Toxic (drugs)
- Infectious
- Genetic
- Traumatic (physical or acoustic)
23
Q
What 2 diuretics can cause a temporary hearing loss?
A
Lasix and ethacrynic acid (Loops)
24
Q
The combination of a loop diuretic with what other type of drug amplifies ototoxic effects?
A
Aminoglycosides
25
What class of antibiotics and what 2 specific drugs are known to cause hearing loss?
Aminoglycosdes, Gentamicin and tobramycin
26
What drug can cause a reversible sensorineural hearing loss?
Salicylates
27
Upon stopping salicylates due to hearing loss, how long does it take for hearing to return to normal?
1 week
28
High-pitched tinnitus should make you think of hearing loss due to what?
Salicylate
29
Name 6 infectious causes of in utero sensorineural hearing loss
1. CMV
2. Measles
3. Mumps
4. Rubella
5. Varicella
6. Syphilis
30
Sudden onset of bilateral sensorineural deafness should make you think of what?
Viral labyrinthitis
31
What is the prognosis for viral labyrinthitis?
Variable
32
What is treatment for viral labyrinthitis?
No treatment, just watchful waiting
33
True or False: Repeated exposure to loud sounds (music, power tools) can lead to high frequency sensorineural hearing loss
True
34
What is the most common cause of sensorineural hearing loss?
Congenital CMV
35
True or False: Infants with congenital CMV may pass their newborn hearing screen
True (and they can develop profound hearing loss by age 1
36
What is the most common cause of childhood sensorineural hearing loss among acquired infections?
Bacterial meningitis
37
When does sensorineural hearing loss occur during bacterial meningitis?
Early (within first 24 hours)
38
What screening test is important to remember in all children with meningitis?
Hearing test ASAP
39
True or False: Development of sensorineural hearing loss in bacterial meningitis is directly related to the severity of illness?
False: Not related to severity of illness, age, or when antibiotics were started
40
True or False: More than 500 causes of syndromic hearing loss have been reported
True
41
What is an X-linked condition that has bilateral sensorineural hearing loss and hematuria?
Alport Syndrome
42
What category of disorders are a big cause of genetic hearing loss?
Mitochondrial disorders
43
What are risk factors for sensorineural hearing loss that are associated with prematurity?
1. Extended assisted ventilation
2. Hyperbilirubinemia
3. Low birth weight
44
What type of therapy poses a risk factor for sensorineural hearing loss?
Radiation therapy (for head/neck tumors)
45
What type of anatomical abnormalities are associated with sensorineural hearing loss?
Craniofacial
46
Name 1 specific syndrome associated with sensorineural hearing loss
Waardenburg
47
When should identification of hearing loss be done by?
3 month
48
When is intervention for hearing loss optimal by?
6 months
49
What are the 2 screening tests for newborns in the nursery?
1. Auditory brainstem response (ABR)
| 2. Otoacoustic emissions (OAE)
50
True or False: A completely deaf child will have normal language development until 9 months of age
True
*Cooing and babbling don't depend on hearing
51
What test uses electroencephalographic waveforms to determine a child's perceptual threshold?
Auditory Brainstem Response
52
After what age would a child likely need conscious sedation for an ABR (auditory brainstem response)?
After 6 months
53
What hearing test is used for infants who are under 6 months of age?
BOA- Behavioral Observational Audiometry (BOA)
54
What type of test is a BOA (behavioral observational audiometry)?
Screening
55
What is the next step for an infant who fails BOA?
They need ABR testing
56
What type of hearing test is used for older infants and toddlers (6 months-2 years)?
Visual reinforcement audiometry (VRA)
57
What test evaluates for bilateral hearing loss?
VRA
*This is important to do so that intervention to prevent language development impairment can be started ASAP
58
What is required is a patient fails a hearing screen or has equivocal results?
They need referral to audiology
59
What is done to assess hearing in a patient with physical, cognitive, or behavioral concerns that may interfere with administration of a hearing screen?
Referral to audiology
60
Who is the conventional pure-tone audiometry screen appropriate for?
School-age children (they have to be able to cooperate with commands)
61
True or False: The conventional pure-tone audiometry screen can test hearing in each ear independently?
True
62
What usually causes results of a tympanometry screen to be normal versus abnormal (on test)?
Technique
63
What is an example of poor technique for a tympanometry screen?
Probe being wedged against external canal
64
True or False: Tympanometry measures hearing sensitivity
False
*You can have a normal tympanogram with significant sensorineural hearing loss or an abnormal tympanogram with normal hearing
65
By what age should infants with significant congenital sensorineural hearing loss receive targeted intervention by?
6 months
66
What are 2 examples of targeted intervention for infants with significant congenital sensorineural hearing loss?
Hearing aids (external) or cochlear implant (implantable)
-This will allow them to hear and develop normally.
67
What does a flat line on a tympanogram mean?
Stiff tympanic membrane, middle ear fluid, or obstructed tympanostomy tube
68
What is another phrase for a flat line on a tympanogram?
Low amplitude
69
What is a high line on a tympanogram associated with?
Hypermobile TM
70
What does the area under the tympanogram curve reflect?
Area in the external canal
71
What does a high volume on a tympanogram curve reflect?
Continuity between the middle and outer ear- Perforated TM (trauma, myringotomy tubes)
72
What will you see on a tympanogram that reflects the absence of pressure and mobility?
High volume (from a perforated TM)
73
What 2 diagnoses fall under otitis media?
1. Acute otitis media (AOM)
| 2. Otitis media with effusion (OME)
74
What are common features of presentation between AOM and OME?
Fluid behind TM
75
What distinguishes AOM from OME?
AOM: Inflammation (erythema of TM and pain)
OME: No inflammation
76
How are AOM and OME best diagnosed?
Pneumatic otoscopy
77
True or False: Erythema of the TM is enough to diagnose AOM?
False- Multiple things can make TM erythematous (fever, crying, ect.)
78
What are the most common bacteria to cause AOM?
1. S. Pneumoniae
2. H. Flu (non-typeable)
3. Moraxella catarrhalis
4. Strep pyogenes (Group A Strep)
79
Which cause of bacterial AOM is increasing in frequency and which is decreasing?
Non-typeable H. Flu is increasing
| S. Pneumoniae is decreasing
80
4 year old with chronic purulent drainage through perforated left TM... best treatment?
Topical/Otic ofloxacin with daily suctioning of canal (allows abx to reach infection)
This is chronic suppurative otitis media (with chronic drainage this isn't AOM, with no keratinized epithelial tissue this isn't cholesteatoma)
81
What is the most common cause of chronic suppurative otitis media?
Pseudomonas
82
What is treatment for chronic suppurative otitis media?
Topical/Otic ofloxacin with daily suctioning of canal (allows abx to reach infection)
83
Name 3 potential causes of chronic suppurative otitis media
1. Pseudomonas
2. Staph
3. Fusobacterium necrophorum
84
True or False: Cholesteatoma and chronic suppurative otitis media can occur together
True
85
What can result from chronic suppurative otitis media?
Cholesteatoma
86
True or False: Chronic suppurative otitis media can occur without cholestatoma?
True
87
If a chronic suppurative otitis media doesn't respond to treatment, what should you consider?
Cholesteatoma
88
True or False: Antibiotic prophylaxis is recommended for the prevention of recurrent otitis media
False
89
Antibiotic prophylaxis in the setting of prevention for recurrent otitis media is a risk factor for what?
Colonization with resistant pneumococcus
90
What is the treatment of choice for recurrent otitis media?
Tympanostomy tubes
91
What should you keep in the back of your head with a child being treated for OM who isn't responding and has symptoms including fever, irritability, lethargy, headache, double vision, and vomiting?
Meningitis
92
What % of the time do intracranial suppurative complications of otitis media occur?
1%
93
True or False: Withholding antibiotic treatment for 48-72 hours to see if symptoms persist in OM is considered correct treatment
True
94
In what % of time does OM resolve in 2 weeks without treatment?
80%
95
What is treatment warranted for OM?
Rapid onset of symptoms, severe pain and/or erythema, infants and toddlers under 2 years
96
True or False: For a child with OM, it is okay to provide a prescription for antibiotics and advise the parents to wait up to 3 days to see if symptoms persist
True
97
What is initial antibiotic choice for OM?
High dose amoxicillin (90mg/kg/day)
98
For a patient with severe OM, what is the first line treatment?
Amoxicillin-clavulanate
99
If a child with OM has a type 1 allergy to PCN, what do you use?
Azithromycin or clarithromycin
100
What should you give for a child with OM who has a treatment failure after 3 days of amoxicillin?
1. High-dose amoxicillin-calvulanate for 1-3 days
| 2. IM ceftriaxone (50mg/kg)
101
What can chronic otitis media with effusion result in?
1. Hearing loss
| 2. Language delay
102
Which patients have an increased risk of otitis media with effusion?
1. Allergic rhinitis
2. Adenoidal hypertrophy
3. Eustachian tube abnormalities
103
What is management for chronic otitis media with effusion?
Monitoring over time (periodic checks of TM mobility)
104
What situations would you consider prophylactic antibiotics in a child with middle ear effusion?
Underlying medical problem...
1. Cleft palate
2. Immunodeficiency
* Have to consider risks of potential bacterial resistance
105
If otitis media with effusion leads to recurrent acute OM or hearing loss, what may be indicated?
Tympanostomy
106
Name 8 conditions associated with recurrent otitis media
1. Under 2
2. Atopy
3. Bottle propping
4. Ciliary dysfunction
5. Craniofacial abnormalities
6. Child care attendance
7. Immunocompromising conditions
8. Sinusitis
107
True or False: Antihistamines, decongestants, and OTC cold remedies as treatment for or prevention of AOM have no proven value
True
108
Oral decongestants should not be used in children younger than what age?
6 years
109
Why can nasal decongestants be harmful to infants younger than 6 months of age?
Rebound nasal congestion can impact respiratory function (infants are nasal breathers)
110
5 year old with tympanostomy tubes has 3 days bloody otorrhea and nasal congestion, PE shows a large erythematous mass...most likely cause?
Tympanostomy tube granuloma (common complication of tympanostomy tubes)
111
What are 2 tumors that occur in the middle ear and can cause bloody otorrhea?
1. Rhabdomyosarcoma
| 2. Eosinophilic granuloma
112
True or False: Otorrhea can occur after tympanostomy tubes are in place
True- Tympanostomy tubes don't prevent URIs, they only equalize pressure
113
What are 3 sources of otalgia that don't involve the ear?
1. TMJ dysfunction
2. C-spine abnormality
3. Sore throat
114
What is a clue in history that could point to a foreign body in the ear?
Child with developmental delay
115
What are 2 findings you might see with a foreign body in the ear?
1. Pain on movement of the pinna (similar to otitis externa)
| 2. Otorrhea
116
"Pain when the pinna is manipulated"
Otitis externa
117
What activity would you associate with otitis externa?
Swimming
118
True or False, you can see purulent discharge in otitis externa?
True
119
What is the usual cause of otitis externa?
Pseudomonas
120
What is treatment for otitis externa?
Antibiotic/steroid drops
121
How can you prevent swimmer's ear?
Acidify ear canal (OTC boric acid or acetic acid solutions) before and after swimming
122
What should you do for a patient with swelling and deformity of the external ear following blunt trauma?
Needle aspiration to evacuate hematoma
123
What is the most common suppurative complication of AOM?
Mastoiditis
124
What are 3 findings commonly seen in mastoiditis?
1. Postauricular swelling and erythema
2. Tenderness over mastoid
3. Outwardly displaced pinna
125
What are 4 most common bacteria to cause mastoiditis in children?
1. Strep pneumo
2. H. Flu (non-typeable)
3. S. Pyogenes
4. S. Aureus
126
How do you diagnose mastoiditis?
Confirmed by CT and tympanocentesis with culture
127
True or False: A negative culture rules out mastoiditis
False (especially if patient was already started on antibiotics)
128
What is treatment for mastoiditis?
IV antibiotics and surgery
129
Acute onset of self-limited vertigo in the absence of vomiting or loss of consciousness?
Benign paroxysmal vertigo
| usually a brief episode presenting in a toddler
130
What are two additional symptoms you can see with benign paroxysmal vertigo?
Nystagmus and pallor
131
True or False: If vertigo lasts hours-days, benign paroxysmal vertigo is unlikely
True
132
If you see hearing loss with vertigo, what is the more likely diagnosis
Labyrinthitis
133
What are the most common causes of rhinitis?
Allergy, sinusitis, polyps, cystic fibrosis, foreign body
134
A nasal smear with lots of eosinophils is most likely what?
Allergic rhinitis
135
In an adolescent with nasal congestion, what should you remember to think of?
Cocaine use
136
Cyanosis with feeding that resolves with crying?
Choanal atresia
137
What syndrome is associated with choanal atresia?
CHARGE
[Coloboma, heart defects, atresia choanae, retardation of growth/development, GU problems, ear abnormalities]
138
In pre-adolescents, how can sinusitis present?
Persistent URI (not necessarily facial pain like in teens/adults)
139
Persistent nighttime cough, foul breath with persistent nasal congestion, toothache, sore throat, poorly controlled asthma, symptoms lasting longer than 7-10 days?
Acute sinusitis
140
Name 4 things nasal polyps are associated with
1. CF
2. Asthma
3. Chronic allergic rhinitis
4. Chronic sinusitis
141
You have a patient with nasal polyps, what test should you order next?
Sweat chloride test
142
What two sinuses are present at birth?
Maxillary and ethmoid
143
What age to the sphenoid and frontal sinuses develop?
5-6 years
144
What organisms cause most sinus infections?
1. Pneumococcus
2. Non-typeable H. Flu
3. Moraxella catarrhalis
145
What is first line antibiotic for sinus infections?
Amoxicillin
146
Child with a sinus infection who recently got amoxicillin and/or goes to day care, what antibiotic should you consider?
1. Amoxicillin/clavulanate
| 2. IM ceftriaxone
147
True or False: Sinusitis is usually a clinical diagnosis
True
148
Why are sinus XR not a good diagnostic tool?
Cannot distinguish between URI and sinusitis
149
What is orbital cellulitis a direct result of?
Ethmoid sinusitis (Eye/Ethmoid)
150
What could result from frontal sinusitis?
Brain abscess (frontal assault)
151
What is needed for any trauma that involves a fracture of the frontal sinus?
Surgical consult and repair
152
Why must fractures that involve the frontal sinus be repaired?
Avoid a CNS infection
153
True or False: Nasal swab cultures and throat cultures correlate well with sinus cultures
False
154
True or False: Oral decongestants, nasal steroids, and antihistamines provide significant help in acute sinusitis?
False
155
How does chronic sinusitis present?
Profuse nasal discharge, tenderness over sinuses, fever, nighttime cough
156
Name predisposing factors for chronic sinusitis
Allergy, exposure to tobacco smoke, recurrent viral URIs, GER, anatomic abnormalities, immune deficiency, primary ciliary dyskinesis (immotile cilia syndrome), and CF
157
What is the treatment for chronic sinusitis?
Antibiotics
| + Surgery if needed
158
How long might chronic sinusitis take to resolve?
2-3 months (of treatment)
159
What should you think of with unilateral, blood-tinged, foul-smelling nasal discharge?
Nasal foreign body
160
What is the study of choice for chronic recurrent sinusitis?
CT
161
When is MRI indicated in chronic recurrent sinusitis?
If an intracranial complication is suggested in the history
162
What is epistaxis due to?
Dry air
163
What is the treatment for epistaxis?
Largely supportive
164
What 4 things should you think to question in epistaxis?
1. Could it be foreign body
2. Vascular anomalies
3. Bleeding disorders in family history
4. Bleeding/bruising elsewhere
165
What is required to identify a posterior bleeding source for epistaxis?
Nasopharyngoscopy
166
How do you identify an anterior bleeding source for epistaxis?
Often visible on exam
167
13 year old boy with recurrent epistaxis that is increasing in frequency and severity and takes more time to stop. Next step in management?
CT scan- Rule out posterior nasopharyngeal mass like a nasopharyngeal angiofibroma
168
Worsening epistaxis?
Consider a nasopharyngeal mass, consider CT
169
Malaise, anorexia, chills, pharyngitis with exudate, fever, palpable cervical lymph nodes, hepatosplenomegaly?
Mono
170
Generalized symptoms, gets ampicillin, develops a rash...?
Think Mono (this is not a penicillin allergy)
171
What virus causes Mono?
EBV
172
True or False: EBV is usually asymptomatic in preschool children
True
173
How long is the incubation period for mono in school age children (and beyond)?
2-7 weeks
174
What are the common features between strep pharyngitis and EBV mono?
Pharyngitis with exudate, enlarged tonsils, fever
175
How can you distinguish strep pharyngitis from EBV mono?
Hepatosplenomegaly is only with mono
176
True or False: A positive rapid strep or throat culture rules out mono
False- Make sure to watch out for signs that the patient is an asymptomatic carrier of strep
177
Whenever you have a patient with a positive strep, what is something you need to consider?
If they are an asymptomatic carrier and it is actually another diagnosis (Mono, ect.)
178
What 2 viruses can cause mono?
CMV and EMV
179
What is the difference between EBV mono and CMV mono?
CMV mono kids are older with mainly fever and malaise
180
3 year old with high fever, swollen lymph nodes, other signs suggestive of mono. Monospot is negative, next step?
Obtain EBV IgM/IgG titers- Monospot screen frequently negative in young children
181
In what age group is the monospot not as sensitive?
Children younger than 4
182
True or False: Patients with an initial negative monospot can become positive 2-3 weeks into their illness
True
183
How long can antibody titers for mono be detectable?
Up to 9 months after onset of illness
184
True or False: A positive monospot test means active/current illness?
True
185
What needs to be done for kids under 4 with a negative monospot and consistent symptoms?
Viral specific IgM
186
What are 2 lab findings consistent with mono?
Lymphocytosis and thrombocytopenia
187
What makes a definitive diagnosis of mono?
IgM antibodies (not isolation of the virus)
188
What are 2 components of treatment for mono?
1. Restricted activity is spleen is big
| 2. Steroids if there is airway obstruction
189
What is the most common cause of pharyngitis in kids with fever and sore throat in absence of URI symptoms?
Group A beta hemolytic strep
190
Name cause of pharyngitis
1. Strep
2. EBV
3. Neisseria
4. Adenovirus
191
How is strep pharyngitis diagnosed?
Culture or rapid strep
192
What is the treatment of choice for strep?
PCN
193
True or False: Waiting for culture results doesn't affect treatment outcome in strep pharyngitis
True
194
What is the purpose of treating strep?
1. Shortens the course
| 2. Prevents development of complications (rheumatic fever or abscess)
195
True or False: Negative rapid strep needs a throat culture due to high rate of false negatives
True
196
What should be done for a patient with recurrent symptoms after treatment for strep throat?
Repeat culture
197
Why might a patient who was recently treated for strep throat have a repeat culture that is positive?
1. Chronic carrier state
2. Second infection (another group A strain)
3. Noncompliance
198
Typical presentation for gonococcal pharyngitis?
Sexually active teen with history of STIs
199
What is seen on the physical exam in gonococcal pharyngitis?
Erythematous patches
200
If you are suspicious of gonococcal pharyngitis, what else should you test for?
Other STDs
201
Dysphagia, difficulty opening mouth, unilateral swelling around the tonsil, deviation of uvula to one side, exudate?
Peritonsillar abscess
202
Trismus, drooling, muffled "hot potato" voice, cervical adenopathy?
PTA
203
What typically causes a PTA?
Varies- Group A strep, mouth anaerobes
204
What are some antibiotic choices for PTA?
1. Ampicillin/sulbactam
2. Clindamycin
3. Amoxicillin/clavulanate
205
How is a PTA diagnosed?
CT
206
What lab findings can you see with a PTA?
Elevated WBC
207
What is needed to protect the airway and provide symptomatic relief in a PTA?
Needle aspiration and drainage
208
Name indications for tonsillectomy
1. Repeated throat infections
2. Airway obstruction
3. Malignancy
209
Name indications for adenoidectomy
1. Chronic sinusitis and/or adenoiditis
| 2. OSA
210
What is velopharyngeal insufficiency?
Complications of tonsillectomy and/or adenoidectomy (presents with a hypernasal voice)
211
Young child with enlarged lymph nodes, high fever, difficulty swallowing, refusal of feedings, drooling, respiratory difficulties?
Retropharnygeal abscess (RPA)
212
How is a RPA diagnosis confirmed?
CT
213
How might a child with an RPA hold their neck?
Hyperextended, stiffly
214
Lateral neck film with widening of the retropharyngeal space or of the paravertebral soft tissues?
RPA
215
How can you distinguish epiglottitis versus RPA?
Epiglottitis is more toxic, scared and leaning forward (verus neck hyperextension or stiffness)
216
What usually causes epiglottitis?
H. Flu type B
217
What 3 things in history could make you think epiglottitis?
1. Unknown immunization record
2. Parental vaccine refusal
3. From a developing country
218
True or False: RPA is a surgical emergency
True
219
What is management for RPA?
Needle aspiration under general anesthesia
220
What bacteria cause RPA?
1. Strep viridans
2. Group A strep
3. S. Aureus
4. Anaerobic bacteria
221
What are the best antibiotics for RPA?
1. Clindamycin
| 2. Ampicillin/Sulbactam
222
True or False: Throat swab culture is helpful in RPA management
False
223
Which age group is RPA more common in?
Children under 4
224
Several days of fever, fussiness, decreased appetite, 4-5mm ulcers in the posterior oral cavity?
Coxsackievirus Group A herpangina
225
Vesiculiopapular lesions on the hands and feet +/- Several days of fever, fussiness, decreased appetite, 4-5mm ulcers in the posterior oral cavity?
Hand-Foot-Mouth (Coxsackievirus Group A herpangina)
226
Vesicles on the vermillion border of the lips and possibly in the anterior mouth, gums, and tongue with mucosal pain, fever, and adneopathy?
HSV gingivostomatitis
227
What is the name for a canker sore?
Apthous ulcer
228
Grayish-white coagulum surrounded by a thing rim of bright erythema in the mouth?
Apthous ulcer
229
What is the natural course of an apthous ulcer?
Resolve on their own over a week or so
230
Infant under 1 with tender red nodules on the cheek, afebrile, good PO intake?
Cold-Induced Panniculitis
231
What is a common cause of cold-induced panniculitis?
Sleeping with a water-filled pacifier or something else very cold
232
What is the description of the lesions in cold-induced panniculitis?
Deep-seated plaques and nodules that are tender and red on the cheeks
233
What is the treatment for cold-induced panniculitius?
None necessary. lesions clear on their own within weeks without scarring
234
Up to what age is the normal waiting time for a first tooth to erupt?
16 months (no intervention needed up to this point in the absence of other findings)
235
Name 5 common causes of delayed eruption of teeth
1. Hypothyroidism
2. Hypopituitarism
3. Hypoplasia (ectodermal)
4. Hypohidrosis (decreased sweating)
5. Rickets
236
How long do you have to get an avulsed permanent tooth back into the socket to give it an excellent chance to survive?
5 minutes
237
True or False: Any capable adult should reimplant and avulsed tooth?
True
238
If you need to transport a permanent tooth, what should you transport it in?
Saliva (patients) or milk (chilled)
239
Should you attempt to replace an avulsed baby (deciduous) tooth?
No- this can cause damage to incoming permanent tooth
240
How can a maxillary dental abscess present?
Facial swelling- Impacts periorbital tissue which impacts ability to open eye
241
How does a mandibular dental abscess present?
Swelling below the jaw
242
What is the antibiotic of choice for a dental abscess?
PCN
243
In a PCN allergic patient, which antibiotic would you choose for a dental abscess?
Clindamycin or erythromycin
244
Which ethnic group are cleft palates most common in?
Native Americans and Asians
245
Which ethic group are cleft palates least common in?
African Americans
246
What should you always think of with a cleft palate?
Pierre-Robin Sequence (PRS)
247
What is involved in Pierre-Robin Sequence?
1. Micrognathia
2. Posteriorly-displaced tongue
3. U-shaped cleft palate
248
What is the initial defect in Pierre-Robin Sequence?
Failure of mandible to grow properly
249
True or False: Cleft lip (with or without cleft palate) is more common in males
True
250
What proportion of children with a cleft lip have an associated cleft palate?
2/3
251
When is repair of a cleft lip done?
Around 10 weeks of age
252
Which gender is cleft palate alone more common in?
Females
253
True or False: Cleft palate alone has the highest risk of being associated with a syndrome
True
254
When is a cleft palate alone usually repaired?
Between 9-12 months of age
255
What is usually part of the surgery to correct a cleft palate?
PET placement (pressure equalizing tubes)
256
Which specialist should see any newborn with a cleft?
Genetics
257
What are some risks and complications that children with cleft palate have?
Eustachian tube dysfunction, vision, hearing, dental, and speech complications
258
What is needed for children with cleft palate to feed?
Special nipples initially
259
Name 3 syndromes besides Pierre-Robin Sequence that are associated with cleft palate
1. Crouzon Syndrome
2. Apert
3. Tracher Collins Syndrome
260
What are 3 things a bifid uvula can be assocaited with?
1. Submucous cleft palate
2. Velopharyngeal insufficiency
3. Middle ear effusion
261
What is it called when airflow ceases because the upper airway is occluded?
Obstructive apnea
262
What should you consider with behavior problems, FTT, developmental delay, or poor academic performance in a kid who snores or has restless sleep?
OSA and sleep-disordered breathing
263
Name 5 clues for underlying OSA or SDB
1. Dysmorphic facies
2. Persistent mouth breathing
3. Hyponasal speech
4. Cleft palate
264
What are 2 things that can result from untreated OSA?
1. Cor pulmonale
| 2. Death
265
What is OSA often due to?
Adenoid hypertrophy
266
True or False: the adenoids are not typically visible on a routine exam
True- So still consider OSA even if there is no tonsillar hypertrophy
267
How is OSA usually diagnosed?
Clinically
268
What image may help confirm adenoid hypertrophy in diagnosing OSA?
Lateral neck radiographs
269
What is the gold standard for diagnosing OSA?
Polysomnography
270
True or False: Lab tests aren't usually helpful in diagnosing OSA
True
271
What lab findings can be seen in severe cases of OSA?
1. Polycythemia
2. Respiratory acidosis
3. Compensatory metabolic alkalosis
272
What EKG finding may be seen in severe OSA?
RVH
273
What is the treatment of choice for OSA?
Adenoidectomy
274
What is treatment if OSA is complete (complete laryngeal atresia or severe web)?
Tracheotomy
275
What are two examples of causes of OSA that may require a permanent tracheostomy?
Subglottic stenosis and complete vocal cord paralysis
276
Post-op patient from a T&A who is in respiratory distress (history of severe OSA)... most likely cause for acute distress?
Pulmonary edema (common post-op complication in severe OSA)
277
What causes stridor?
Turbulent flow through a narrowed segment of the respiratory tract
278
Why is stridor a prominent feature of respiratory disease of the newborn?
Because the normal airway in a newborn is so narrow (Kids over 2 will have stridor for other reasons)
279
What is important to note in the history of a kid with stridor?
Age
280
Name 4 causes of stridor in a neonate
1. Choanal atresia
2. Larngeal web/stenosis
3. Vascular ring
4. Vocal cord paralysis
281
Name 2 causes of stridor in a child who is 4-6 weeks old
1. Laryngomalacia
| 2. Tracheomalacia
282
Name 3 causes of stridor in a child who is between 1 and 4
1. Croup
2. Epiglottitis
3. FBA
283
Name 3 causes of stridor in a child over 5
1. Vocal cord dysfunction
2. PTA
3. Anaphylaxis
284
What causes inspiratory stridor?
Extrathoracic (above the thoracic outlet) obstruction- All of these structures are soft and collapse inward with pressure of inspiration
285
Where are supraglottic, glottic, and subglottic areas located?
Extrathoracic (inspiratory stridor)
286
If the supraglottic, glottic, and subglottic areas are affected, what type of stridor will you have?
Prominent inspiratory (extrathoracic structures)
*If you are lower down there is a chance for expiratory stridor too
287
What is assocaited with swelling and inflammation of the tonsils and adenoids in addition to pharyngela and hypopharyngeal masses?
Inspiratory stridor
288
Name 4 causes of inspiratory stridor
INSP
1. Immobile cords (Paralysis)
2. Adenoid and tonsil enlargement
3. Soft cartilage (laryngomalacia)
4. Pharyngeal and hypopharyngeal amsses
289
What is the condition where the tissues at the entrance of the larynx collapse into the airway with inspiration?
Laryngomalacia
290
What is the most common cause of congenital stridor?
Laryngomalacia
291
What is a PE finding in laryngomalacia?
Suprasternal and subcostal retractions
292
When does stridor due to larngomalacia worsen?
With agitation (under 1 month of age) and when infant is supine
293
When does stridor due to laryngomalacia improve?
With expiration
294
Why does stridor due to laryngomalacia improve with expiration?
Pressure from below stents open the floppy airways
295
True or False: Stridor due to laryngomalacia improves with time
True (as cartilage becomes firmer
296
What is seen on spirometry in vocal cord paralysis?
Blunted inspiratory loop
297
Name 3 associations with vocal cord paralysis
1. Recent viral URI
2. Exposure to chemicals, fumes, or cold air
3. GERD
298
What is the second most common cause of extra-thoracic airway obstruction and stridor in infancy?
Vocal cord paralysis
299
What is vocal cord paralysis usually due to?
Traumatic injury of the recurrent laryngeal nerve at time of birth or due to impairment in CNS
300
What does the cry sound like in vocal cord paralysis?
Weak
301
How do you differentiate between stridor due to laryngomalacia and vocal cord paralysis?
1. Laryngomalacia is inspiratory stridor that is wet sounding or variably pitched
2. Vocal cortd paralysis is inspiratory stridor that is high pitched
302
How does unilateral vocal cord paralysis present?
Persistent hoarseness
303
What are 2 things that can cause a weak cry in early infancy and how do you distinguish?
Vocal cord paralysis and laryngeal webs- Changing position will effect clinical symptoms in vocal cord paralysis, but not laryngeal webs
304
Child with FTT who has respiratory difficulties- Would laryngomalacia be on your differential?
No- infants with laryngomalacia feed without difficulty and gain weight
305
Progressive hoarseness that is less severe in the morning with no stridor or dysphagia?
Vocal cord nodules
306
Most cases of chronic hoarseness in children are caused by what?
Vocal cord nodules
307
Which gender are vocal cord nodules more common in?
Males
308
When do vocal cord nodules tend to improve?
With puberty
309
What diagnosis might be suspected in place of a vocal cord nodule?
Asthma
310
What is something to ask for in history if you suspect vocal cord nodule?
History of endotracheal extubation
311
What is often required to diagnose laryngeal and vocal cord disorders?
Larynoscopy
312
How can you distinguish asthma versus vocal cord dysfunction?
Vocal cord dysfunction has normal pulse ox reading, clear lung fields on exam, and no improvement with bronchodilators
313
Which phase of breathing is problematic in vocal cord dysfunction?
Inspiration (in asthma expiration is the problem)
314
Which lesions cause expiratory stridor?
Below the thoracic inlet
315
What are 2 classic examples of problems that cause expiratory stridor?
1. Tracheomalacia
| 2. Bronchomalacia
316
What is tracheomalacia?
Weak tracheal wall rings- collapse during expiration (rare condition)
317
Besides expiratory stridor, what else can infants with tracheomalacia have?
Wheezing- extrinsic tracheal compression can cause fixed wheezing (also prolonged neonatal ventilator support can cause wheezing so consider this)
318
When is the symptom relief noted in laryngomalacia?
During expiration (opposite of tracheomalacia which is expiratory stridor)
319
What should you consider for a kid with history of TE fistula repair who presents with expiratory stridor?
Tracheomalacia
320
What should you consider for a kid with feeding difficulties and expiratory stridor?
Vascular ring (extrinsic compression-wraps around trachea and esophagus)
321
What type of stridor does congenital and acquired subglottic stenosis cause?
Biphasic stridor- this problem is both intra-thoracic and extra-thoracic
322
For subglottic stenosis, which phase of stridor is often louder?
Inspiratory component
323
What can a subglottic hemangioma result in?
Subglottic stenosis (biphasic stridor)
324
What can a critical obstruction along the airway result in?
Biphasic stridor
325
True or False: With tracheomalacia, if the obstruction is high enough, stridor can be biphasic
True
326
How do you assess for subglottic stenosis?
Direct laryngoscopy and bronchoscopy
*Bronch assess the patency of the subglottis
327
How do you assess for vocal cord function?
Flexible nasolaryngoscopy or direct laryngoscopy, plus a CXR and barium swallow
328
How do you assess for a vascular ring?
Barium swallow study
329
What should be the first thing done for an infant with noisy breathing?
Obtain thorough birth history and observe breathing patterns in different positions
330
What type of stridor does epiglottitis present with?
Biphasic (this is a supraglottic stenosis)
331
Why is epiglottitis rare today?
Hib vaccine
332
4-5 year old with inspiratory stridor, high fever, won't lay down, is positioned leaning forward, tripoding, and drooling?
Epiglottitis
333
What is seen on lateral neck film in epiglottitis?
Thumb sign- Enlarged epiglottis
334
True or False: Cough is common in the presentation of epiglottitis?
False
335
5 D's of epiglottitis?
1. Drooling
2. Dysphagia
3. Dysphonia
4. Distress
5. Deafening stridor
336
What should you look for in history if you suspect epiglottitis?
Parental refusal of all immunizations
Child from another country
*Hib vaccine not given*
337
How do you evaluate for epiglottitis?
Need to be prepared for intubation with anesthesia on board- this is a medical emergency. Until then, keep child in parent's arms and calm
338
If your patient with suspected epiglottitis is table, what labs should you get?
CBCdiff and blood culture
339
What type of antibiotic should be started empirically for epiglottitis?
3rd generation cephalosporin (ceftriaxone or cefotaxime)
340
What is another name for laryngotracheobronchitis?
Viral croup
341
Toddler in fall/winter with a harsh, non-productive barking cough, low grade fever, URI symptoms?
Croup
342
What kind of stridor can be seen in croup?
Inspiratory or biphasic (with worsening of narrowing)
343
What is treatment for mild croup?
Humidified air, fever reduction, PO fluids, exposure to cold night air
344
What characterizes more severe croup?
Stridor at rest or retractions
345
What can be done for more severe croup?
1. Single dose of dexamethasone
2. Nebulized racemic epi
3. Intubation
346
How frequently can racemic epinephrine be given?
Every 15-20 minutes as needed
347
How long do kids who have gotten racemic epinephrine need to be observed before they can be discharged home?
3-4 hours
348
What vaccine-preventable disease can cause croup?
Measles (rubeola)
*Keep this in mind with a kid who is unimmunized, recent immigrant, or unknown immunization status
349
What are the 3 common viruses that can cause croup
1. RSV
2. Influenza
3. Parainfluenza
350
What causes spasmodic croup?
Allergies or psychological factors (no URI or fever)
*Described as a barky nonproductive cough
351
Name 2 other names for bacterial tracheitis
1. Pseudomembranous croup
| 2. Membranous laryngotracheitis
352
What bacteria usually cases bacterial tracheitis?
1. S. Aureus... also consider
2. Moraxella catarrhalis
3. Non-typeable H. influenza
4. Oral anaerobes
353
What should you consider with rapid deterioration of a patient with viral croup?
Bacterial tracheitis- This can occur several days into a bout with viral croup
354
How do patients with bacterial tracheitits present?
Toxic appearing, thick/purulent secretions causing airway obstruction (may even lead to cardiopulmonary arrest)
355
What is seen on a neck film in bacterial tracheitis?
1. Ragged air column
| 2. Subglottic narrowing
356
What position do kids with bacterial tracheitis prefer?
Comfortable supine (whereas epiglottitis is leaning forward and drooling)
357
What is management of bacterial tracheitis?
Typically the patient is deteriorating rapidly
- Intubation is required
- Clear purulent secretions
- Broad spectrum antibiotics (Staph coverage)
358
What are most cases of cervical lymph node enlargement due to?
Infection- Reactive cervical adenopathy
359
How are reactive lymph nodes described?
Mobile and tender (NOT erythematous or warm to touch)
360
When do reactive lymph nodes go away?
Swelling decreases in a few days-weeks
361
Preauricular adenopathy with conjunctivitis?
Adenovirus
362
What should you check for if cervical lymphadenopathy is unexplained or persists?
Check for HIV and TB
363
How does lymphadenitis present?
Node id tender, red, and warm to touch
*The node itself is infected versus being reactive
364
Which type of lymphadenitis is generally bilateral?
Acute viral cervical lymphadenitits
365
How does bacterial lymphadenitits present?
Unilateral, more local inflammation
366
What is the most common bacterial organisms causing acute cervical adenitits?
1. S. aureus
| 2. Group A strep
367
What labs should you consider ordering when dealing with lymphadenitits?
CBC. ESR. blood cultures, PPD, and DNA
368
What is the antibiotic of choice for cervical lymphadenitits?
1. Amoxicillin/clavulante
2. Clindamycin
*Need something that can fight beta lactamase producers
369
What is a good antibiotic for a PCN allergic patient who has cervical lymphadenitits?
Erythromycin
370
What does atypical mycobacteria result in?
Persistent lymph node swelling
371
What happens with a PPD in atypical mycobacteria infection?
10mm or less (less than what you see with TB)
372
What is the treatment for atypical mycobacteria causing cervical adenopathy?
Leave it alone- drugs don't work
373
What may be needed for cervical adenopathy due to atypical mycobacteria?
Surgical lymph node excision
374
When is needle excision indicated for atypical mycobacteria lymphadenopathy?
NEVER- it drains forever
375
What should you consider for a patient with cervical adenitis who isn't responding to antibiotics?
Mycobacterium tuberculosis (look for other TB risk factors)
376
True or False: Both TB and nonTB mycobacteria turn a PPD positive
True
377
How can you differentiate TB and nonTB mycobacteria?
Check an IGRA (quantiferon or T-spot blood test)
*Positive in TB, Negative in nonTB
378
What age group is the IGRA (quantiferon or T-spot blood test) approved in?
Kids 5 and older
379
What bacteria is an important cause of acute cervical lymphadenitis in infants?
Staph (surgical drainage may be necessary)
380
Describe a lymph node that is malignant
Nontender, firm, non-mobile/fixed, doesn't shrink in size over time (like a reactive node)
381
What do you need to think of if you have lymphadenopathy around the thyroid?
This could be thyroid carcinoma
382
What do you think of with any midline lesion on the anterior neck?
Thyroglossal cyst
383
When do you remove a thyroglossal cyst?
You don't- this is often the only functioning thyroid tissue
384
Midline lesion on the anterior neck that moves vertically with swallowing or sticking the tongue out
Thyroglossal cyst
385
True or False: A thyroglossal cyst can have communication with the skin which results in draining
True
386
What is a mass of dilated lymph vessels that can be described as a large soft neck mass?
Cystic hygroma
387
How does viral parotitis present?
- Pre-school or school-age children
- Parotid swelling
- Vague symptoms (weakness, fever)
- Swelling and erythema around opening of Stensen's duct (typically no pus can be expressed)
- No erythema of overlying skin
388
In a child with suspected viral parotitis who is unimmunized, what should you consider?
Mumps
389
With viral parotitis, what features should you consider in the presenting history?
Anything pointing towards HIV infection
390
How does bacterial parotitis present?
Occurs before age 10, child is toxic-appearing with very high temp
391
What bacteria is the most common cause of bacterial protitis?
S. Aureus
392
How does a salivary gland stone present?
Recurrent swelling of both parotid glands
393
Patient from developing country with parotid swelling of few weeks time that has been resistant to antibiotics. No information on parents, child got some vaccines, but not well-documented... Most appropriate study for diagnosis?
HIV testing- this is viral parotitis (no knowledge of biological parents and did get some vaccines- points away from mumps)
